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Friday, March 7, 2014

Dr Christine Hawke, founder of Sydney Pet Dentistry, and dental veterinarian at the Animal Referral Hospital, is a wonderful human being. She taught immunology and dentistry when I studied veterinary school, and she's made a huge dent (no pun intended) in companion animal welfare by promoting awareness of their dental health. I've consulted her over some tricky cases including Phil's extraordinary dental disease.

SAT had a chat with her about her career, and why dental treatment important to animal welfare. (Readers who missed it might also like to read my summary of Dr Hawke's awesome feline dental extraction lecture last week).

Tell us a bit about yourself. Who
are you and what do you do?

I am a dental veterinarian, meaning I only do mouths (dentistry and oral
surgery). I also do a lot of teaching in vet dentistry.

Was there a lightbulb moment in
your life when you decided you wanted to be a vet?

I have wanted to be a vet since I was five. My whole life plan was based
on the whim of a five year old!! Luckily, I was obviously very in touch with
myself at that age, as it was definitely the right decision (thankfully!). I
did consider other options briefly (novelist, photographer, paediatrician) but
really, it was always going to be vet science. Funnily enough, dentistry itself
never crossed my radar!

Were any non-human companions
influential in this decision. Who were they?

Not really. I have always loved animals, I grew up with cats (my brother
was allergic to dogs), and went to an agricultural high school so there was a
lot of exposure to farm animals there, but the decision was made very early on.
The animals in my life just confirmed it along the way.

What moved you to focus solely on
dentistry?

It’s funny, I actually hated dentistry when I was working in general
practice for my first few years after graduating. We were not taught dentistry
at university, so I did not understand it, and I don’t enjoy doing things I
don’t understand! My plan in my early career was to travel a lot (which was
made easy being a vet), then to settle down and specialise in internal
medicine.

I completed a PhD in immunogenetics before my career went on hold when I
fell pregnant with my first child. I then started working at the University of
Sydney in the veterinary teaching hospital. As part of that job, I had to
either teach desexing or dentistry – and I chose dentistry (anything to avoid
doing big dog speys!). The rest is history!

Dentistry is an area that has only
recently received attention in the last decade or so. Why has companion animal
dentistry been neglected for so long and do we still have a way to go?

Dental disease is THE most common health problem in dogs and cats – far
more common than heart disease, cancer, diabetes, and even obesity! An
estimated 80% (yes that is not a misprint) of pets over the age of three have
dental or oral disease.

Severe gingivitis in a cat.

I think the main reason dentistry has been relatively neglected is that
people (many vets included) have simply not realised how important it is.
Dental disease is insidious, silent and hidden in the dark. Unlike the obvious
signs we see with other painful issues (like limping with a sore leg, weeping red
skin or head-shaking with an ear infection), dental issues cause few signs. Bad
breath, often the only sign in animals with infected mouths, is widely believed
to be ‘normal’ for dogs and cats (there is nothing normal about bacteria, pus
and rotten egg gas, which is what you are really smelling!). Signs that we’d
associate with dental disease, such as dropping food or not being able to eat, only
develop very late in the process, after months or years of infection and pain.

The improvement in dental health for animals has been fantastic over the
past few years, thanks largely to the work of groups such as the AustralianVeterinary Dental Society. But, with many animals still affected, we still have
a big job ahead to increase awareness.

As part of your role you teach
veterinarians how to expand their dentistry skill set. What are common
weaknesses people ask you to help them address?

Most vets really don’t like dentistry, mainly because they don’t get
great dental training in university (I can totally identify with this). I help
them become confident in recognising disease and competent in treating it, so
they can learn to love it as much as I do! A really big part of it is helping
vets and nurses communicate with pet owners so they really understand the need
for dental care – if the animals won’t tell us they are struggling, then it is
up to us to speak up on their behalf. Often pets don’t get dental treatment because
people think they are fine because they are eating – nothing could be further
from the truth.

The other main skill I love to teach is extraction technique – dental
extractions can be difficult (the roots of carnivore teeth are massive!), and
so it is a real thrill to help others learn better surgical skills to make this
less stressful, both for the vets and the patients!

What do you do that ordinary vets
may not?

In general practice, most vets can perform professional scaling and
polishing, and extractions. While I still spend a lot of time extracting teeth
(especially those big nasty ones), I can also offer alternatives that may save
teeth, such as root canal therapy, periodontal surgery, and even orthodontics! People
always ask whether we do braces for dogs and, yes we can, but not for purely
cosmetic purposes. Any treatment we do is aimed at fixing issues that cause
pain, infection or problems with eating.

Another big part of our service is dental radiology and imaging. About
two thirds of each tooth is buried in bone, so xrays are very important tools
in dental diagnosis and treatment. We also have in-house CT and MRI if needed.

An infected premolar post extraction.

What's involved in a root canal
and why would someone have it performed on their dog? Isn't it easier just to
pull a tooth out?

A root canal procedure is most commonly performed on a tooth that has
been fractured or damaged, and the pulp tissue (living tissue inside the tooth)
has died. Basically, it involves removing all of the dead and infected material
from the root canal inside the tooth, filling the tooth with a material that
stops bacteria from resettling inside the canal, and sealing the tooth with a
filling.

While root canal surgery has a bad reputation in people, it is not as
stressful for our patients, as they are anaesthetised and we aim to do it in
one procedure (in humans it usually takes multiple visits, but we do it in one
stage to minimise the number of anaesthetics needed). Almost all patients are
home within a few hours, and eating the same day as if nothing has happened.

Extracting a dead or damaged tooth is always a better option than
leaving it to rot in place. However, root canal treatment can be a lot less
invasive and allows the animal to keep the function of the tooth. For smaller
teeth, this may not be as important (unless the animal is a show animal or
working dog). The main teeth we treat are the big canines (fangs) and
carnassials (large cutting teeth). The root of the lower canine, for example,
makes up more than half of the front of the lower jaw, so extraction is a big
deal!

While no tooth is critical in a pet living in modern society (as long as
we do the food hunting for them of course!), preserving teeth allows better
function (for example, the canine teeth are a dog’s equivalent of an opposable
thumb), and can help avoid complications of extraction such as jaw fracture,
tongue drooping and lip damage.

Delicately suturing an oronasal fistula in a microdog.

What sort of conditions do people
refer to you?

I see all sorts of things, including broken teeth needing root canal
treatment, bite abnormalities needing orthodontic intervention, oral tumours,
fractured jaws etc. While some hospitals now have dental radiology, those that
don’t may refer patients in for xrays to allow better diagnosis and treatment
of dental problems.

Often vets will refer in cases that need a lot of teeth extracted (such
as severe periodontal disease or gingivostomatitis) as I am a pretty fast
surgeon, so the time under anaesthesia can be greatly reduced. This is
particularly important for patients with other conditions such as heart or
kidney disease, where the risks with anaesthesia are higher.

I see a lot of puppies with bite abnormalities, as we can sometimes
intervene and improve their development when they are young and still growing.
Sometimes I will also help when there has been a difficult surgery, for example
if a tooth root is difficult to extract, or there have been unexpected
complications. I love a challenge!!

Do you ever get sick of teeth?

No. Not a bit. Never. Scary, huh? Maybe I should get out more….

Why do we so often underestimate
dental pain in animals?

Animals are so good at hiding dental pain. Dental disease is hidden in
the dark, inside the mouth. While an animal may not be able to hide a limp, it
can always chew on one side, or swallow food whole, and this can go unnoticed
for months or years. Dogs and cats can suffer extraordinary dental disease
before they get to the point of not eating – they will soldier on until the
prospect of starving to death is preferable to the pain of eating.

Do you have any tips around
dentistry for vets and vet students?

Always look in the mouth – don’t expect pets to tell you, or their
owners, that they have dental issues. Plan your dental surgeries, such as
extractions, with the same consideration as you plan other surgeries – lack of
planning is the biggest reason dental disasters occur. Dental radiographs are
SO important for diagnosis and treatment planning – about two thirds of each
tooth is buried in bone, so without xrays you are truly operating in the dark. Use
good quality, sharp instruments. Finally, have patience - this is a lifelong
learning exercise, but it pays off.

Thank you Dr Hawke! If you're seen for more dental tips, Dr Hawke will be running a workshop through the Centre for Veterinary Education in May (read more here) and will also be speaking at the AVA 2014 Annual Conference (registration here).

Veterinary Ethics: Navigating Tough Cases

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